CurrentMolina HealthcarePolicy N/A

Multiple Procedure Payment Reduction (MPPR) reimbursement

Defines Molina Healthcare's reimbursement methodology for multiple surgical or diagnostic procedures performed by the same provider during a single operative session on the same day; applies to Molina-reimbursed claims and providers submitting those claims.

Policy Summary

PayerMolina Healthcare

PolicyMultiple Procedure Payment Reduction (MPPR) reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionEnsure billing includes necessary indicators and supporting documentation to comply with state Medicaid and/or CMS guidelines to avoid delays, denials, or audits.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%primary procedure reimbursed at

50%secondary procedure reimbursed at

Multiple Procedure Indicator 2CMS alignment

State exceptions listedstate-specific variations called out

Multiple Procedure Payment Reduction (MPPR) — Reimbursement Criteria

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MPPR reimbursement criteria

Payment adjustments when multiple procedures are performed by the same provider in a single operative session on the same day are governed by MPPR as follows:

MPPR applies when multiple surgical or diagnostic procedures are performed by the same provider within a single operative session on the same day (aligned with Multiple Procedure Indicator 2).

Primary procedure reimbursed at 100% of the allowable rate as per the applicable fee schedule.

Secondary procedure reimbursed at 50% of its allowable rate.

Reimbursement for any additional procedures follows state-specific Medicaid regulations or CMS guidelines, whichever is applicable.

Reimbursement calculations are based on the applicable fee schedules and any supplementary contractual arrangements between Molina Healthcare and the healthcare provider; provider contract language prevails where it applies.

Providers must include necessary billing indicators and supporting documentation per state Medicaid program and/or CMS requirements to avoid delays, denials, or audits.

Coding, Rates, and References

Notable coding references and state exceptionsCPT

00100-69999, 96360-96549	Ranges referenced for non-reimbursable when billed with CPT 36000 in CA exception
36000	Not reimbursable in CA when billed by same provider on same date with codes in ranges 00100-69999 and 96360-96549
51701, 51702	Not separately reimbursable with CPT 10021-69979 in CA exception
58611	Tubal ligations reimbursable when performed at time of cesarean or other intra-abdominal surgery (CA Medi-Cal note)

Coding disclaimer (policy-level note)mixed

N/A	Codes listed in this policy are for reference only; listing does not guarantee coverage and may not be all-inclusive. Deleted or ineffective codes at time of service may not be eligible for reimbursement.

Secondary procedure payment rate

Secondary procedure payment rateSecondary procedures reimbursed at 50% of the allowable rate.

Documentation and Billing Compliance

Documentation Required

Documentation and billing compliance required

Providers must include all required procedure indicators and supporting documentation on claims submitted to Molina. Compliance with the billing and documentation guidelines of the applicable state Medicaid program and/or CMS is mandatory to avoid claim delays, denials, or audits.

Include necessary procedure indicators on the claim per state Medicaid and/or CMS guidance.
Attach or retain supporting documentation required to justify multiple procedures in a single operative session.
Non‑compliance may result in delays, denials, or audits.

Definitions and Acronyms

MAC (Medicare Administrative Contractor) definition

DefinitionMedicare Administrative Contractor (MAC): private contractors that process Medicare Part A and Part B claims (and DME claims) and act as the operational link between Medicare and providers for a defined geographic area.

Noridian (MAC)

Jurisdictions servedNoridian handles claims processing and related services for Medicare Parts A and B in Jurisdiction E (JE) and Jurisdiction F (JF).

Novitas (MAC)

Jurisdictions servedNovitas handles claims processing and related services for Medicare Parts A and B in Jurisdiction H (JH) and Jurisdiction L (JL).